1003362898 NPI number — PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF NJ, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003362898 NPI number — PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF NJ, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF NJ, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003362898
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
576 BROADHOLLOW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11747-5002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-359-5859
Provider Business Mailing Address Fax Number:
364-396-0865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
64 RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST HANOVER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07936-3599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-428-1050
Provider Business Practice Location Address Fax Number:
973-428-1051
Provider Enumeration Date:
08/31/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BRUSH
Authorized Official First Name:
KATHLEEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR MANAGER
Authorized Official Telephone Number:
631-359-5859

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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